Boards and Commissions Application

SILC Membership Application

Accessibility and Functional Needs
To make the process below as accessible as possible, the SILC committee is committed to accommodating various needs. If you, or your caregiver, encounter any challenges due to vision, hearing, mobility, cognitive, neurodiverse needs, language barriers, technical limitations or other disabilities, we are here to support you. Alternative formats, such as large print, Braille, simplified text, audio assistance, or one one one help with filling out the application, are available upon request. Please don’t hesitate to call the phone number below for further assistance or to discuss specific accommodations that might work best for you.

Step 1 of 5

Legal Name(Required)

First Middle Last

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Island of Residence(Required)

Contact Phone:(Required)

(###) ###-####

Primary Email Address(Required)

Why do you want to serve on the SILC?

Do you identifies as a person with a disability?

Yes

Prefer not to answer

Do you consider yourself an ally or champion for people with disabilities?

Yes

Are you willing to share your personal lived or learned experience?

Yes

Reference #1

Name

First Last

Phone:

(###) ###-####

Reference #2

Name

First Last

Phone:

(###) ###-####

Reference #3

Name

First Last

Phone:

(###) ###-####

Are you currently serving on any board, commission, or council created by the State Constitution or a state statute?

If so, please state the name of the body and the date when your term expires.

Optionally, please upload your resume:

Max. file size: 80 MB.

Name

This field is for validation purposes and should be left unchanged.